I was privileged to be present when Dr Stephard Hurwitz, President of ABOS (American Board of Orthopaedic Surgery), presented an overview of the functions of the ABOS.

ABOS is a completely independent organisation and is not attached to the American Orthopaedic Association or the American Academy of Orthopaedic Surgeons (AAOS). They function on a national basis and conduct a two-tier exam comprising a multiple choice exam (part 1) and a second phase exam (part 2) for which an Orthopaedic surgeon submits ten cases out of his/her practice and is then examined by three sets of two examiners on these cases.

The pass percentages are not set in stone for the first part but vary according to the difficulty grade of the exam. It usually ends up being around 68%.

The ABOS do not conduct or endorse any review course, for instance, the AAOS courses or Miller review course. They regard themselves as completely independent. The ABOS members may not be in any way attached to or send material in to any review course.

The AAOS on the other hand conducts a yearly OITE exam (Orthopaedic In Training Exam), which comprises multiple choice questions. This exam is written in electronic format and all residents (registrars) PGY 1-5 (first year to fifth year) participate. In other words, you do not pass or fail the exam: you get your score and your Program Director also gets the statistics of how you faired compared to every other resident in your year nationally. You get an idea of your percentile compared to your class. A first-year resident may have a low score but be high on the percentile compared to all other PG1 residents.

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Both the AAOS and ABOS attempt to balance these questions in order to present a fair representation of all Orthopaedic sub-specialties.

In the USA you get into a residency programme by applying, submitting your CV and USMLE (the United States Medical Licensing Examination) scores (to be registered as a MD you have to pass all three USMLE exams). The final placements of residents take place by national allocation done by the Resident Review Committee (RRC). You may live in Florida but you match in Seattle!!

To become an MD you have to go to College (four years) and earn a non-medical College degree majoring in anything. You then enter into Medical School for another four years followed by residency (average five years). By the time you enter your fellowship year after residency, you have about $250 000's worth of debt! You do get an interview at the medical schools where you applied for residency.

What are the selection criteria for a Department of Orthopaedics? - a) USMLE scores; b) a good CV; c) possibly having worked as a student at the specific Department; and d) a residency interview.

The question arises: Is this selection process adequate to select the best and finest residents possible? The answer is no!

Let us look at the South African system:

A registrar candidate finishes six years of medical school (straight), then starts to work as an intern (house doctor) in the seventh year, followed by two years of community service. The candidate then applies for a registrar's position but most of the time will be appointed as a Medical Officer in the Orthopaedic Department, waiting for a registrar post. In the course of being a Medical Officer, some of the departments require the registrar to pass the first part of the FCS exam or the MMed exam (basic science part 1). The candidate also assumes the responsibility of a junior registrar and has the opportunity to assess whether this is really the specialty he/she would like. This also gives the Orthopaedic Department the opportunity to evaluate the candidate for competency at all levels (the proof of the pudding is in the eating!).

The strength of the SA system is exactly that: a registrar is known and most of the time evaluated by the Orthopaedic Department before his/her appointment. In the USA you may get a resident who is virtually unknown to anyone in the department in terms of that person working in the department.

Let us look at the reasons why residents/registrars are released from their duties (asked to leave). The reason is almost never a question of inferior intellectual abilities. It is almost always a personality issue including the inability to communicate, to function with peers, to be reliable, to execute effective patient care or simply to work the long duty hours. These emotional IQ parameters are not evaluated in the US system and Dr Hurwitz himself suggested a future where a resident candidate should work in a department before being appointed as a resident.

My advice for the South African system is to continue appointing registrars who are known to the Orthopaedic Department and who have proved themselves academically as well as practically to 'fit the slot' in that Department.

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It is extremely difficult to get rid of a dysfunctional registrar/resident. It behoves us in the USA therefore to refine our selection process.